Rethinking Madness: A Book Review

“Rethinking Madness: Towards a Paradigm Shift In Our Understanding and Treatment of Psychosis” by Paris Williams, Ph.D., describes how our current mental health system fails not only in devising treatments for psychosis, but also in even thinking clearly about such experiences , and describes what is needed as a replacement.

If madness, or psychosis, is just a result of a physical defect in the brain, then it makes sense to devote little effort to understanding the experiences of mad people, and to focus instead on suppressing such experiences as much as possible. That’s what our vast “mental health” industry has been doing for decades, without success. In this book, Williams outlines a very different approach, one that prioritizes understanding and valuing personal experiences.

Before writing this book, Williams spent time as a hang glider pilot, winning one world championship and several national awards. He then experienced a mental crisis that could have been labeled psychosis, but he avoided getting diagnosed or “helped” by psychiatry, and instead worked through his experiences on his own. This caused him to get interested in helping others, and he became a psychologist and also a researcher interested in detailed exploration of the experiences of people who underwent psychosis and then full recovery. It seems clear that the depth of understanding in the book emerges out of his personal experiences and his interest in the experiences of others, while it may be that his experiences as a glider pilot helped him develop a habit of forming a clear overview of areas to be explored. In any case, the view of madness that emerges appears to be a profound integration which has breadth and well as depth.

One of the key ideas is that psychosis, in the presence of the right conditions, can be expected tomost commonly result in a positive outcome, an outcome that is something better than the state that existed before the psychosis. This assertion flies in the face of most of what our culture thinks it “knows” about psychosis, but the arguments for it are very well documented. This perspective should not be confused with some romantic notion that psychosis is always a good thing – Williams is clear that it is hazardous under the best of conditions, and likely to lead to major ongoing life difficulties when the focus is just on attempts to suppress the process, as usually happens in developed countries today. But what is critical to note is that these poor outcomes are typically a result of a poor handling of the experience, and not of the nature of the experience itself.

Another key idea is that the core issues in madness are not a struggle with an “illness” experienced only by some, but rather a struggle with the existential issues that we all face, such as being caught between a fear of being separate and a fear of being overwhelmed or engulfed by connection. Williams outlines how the ability to regulate one’s approach to such dilemmas is lost in psychosis, usually in response to a number of stressful experiences, but also how the loss of one’s prior approach has the potential to lead to the emergence of new and healthier ways of being organized, which might later benefit not just the individual but also the wider society. He discusses these ideas first theoretically, and then by clear descriptions of how these issues played out for the individuals he researched, as they went through psychosis and then recovery.

Williams is arguing that psychotic experiences typically occur as part of a process of experimentation at a deep level of the mind, a risky process of profound disorganization and then reorganization. He illustrates how standard mental health care interferes with rather than safely facilitates this process, and how recovery seems currently to only be possible when people manage to break away from the system to at least some degree. He then sketches out the possibility of a very different system of care that would recognize the meaningfulness and positive potential in psychotic breakdown, one which would be likely to facilitate rather than impair recovery.

Also, in an upcoming live webinar, you will be able to hear about the central ideas in this book directly from Paris Williams, and you will also have an opportunity to ask questions. This will take place Friday May 18 2012, 10 AM Pacific time, 1 PM Eastern time. Or, if you can't make it on Friday, Williams will repeat the webinar on Saturday, May 19 2012, also at 10 AM Pacific time, 1 PM Eastern time.

Advance registration is required, as limited spots are available. A suggested donation of $10 is requested, although no one will be turned away for lack of funds.

We hope to make recorded copies of this webinar available afterward for people who can’t attend at either of these times. You can contact me at [email protected] if you want to be notified of when this is available, and/or if you would like to hear about future webinars about psychological approaches to psychosis – I am hoping to develop an extensive program of webinars on this subject. In the future, some of these will likely come with CEUs for professionals, but these are not yet available.

Dialogues with Madness: A therapist and educator specializing in cognitive therapy for psychosis, Ron Unger explores emerging understandings of psychosis and of efforts to change mental health treatment to support human rights and full recovery.

13 thoughts on “Rethinking Madness: A Book Review”

“Every page of this book was exciting to me . . . This book should be a part of the training of every physician, psychiatrist, and pastoral counselor, and owned by the family and friends of every mentally ill person as well as the sufferers themselves.” – Joanne Greenberg, bestselling author of I Never Promised You a Rose Garden

“At last, a book that summarizes the very latest–not in brain chemistry–but in the phenomenology of psychosis. A book of profound illumination both for the scholar and the person struggling for his or her psychical life. I highly recommend this book to all those who are touched by the psychotic experience, which really means all of us–and to find out why, just read this book!” – Kirk Schneider, Ph.D., editor of the Journal of Humanistic Psychology, and author of Awakening to Awe and The Paradoxical Self

“Deceptively easy to understand, yet thought provoking and challenging, his work offers plausible reasons to overcome the too simple historical medical approaches that ignore the richness of the human experience and the positive potential inherent in one’s journey through madness.” – Ronald Bassman, Ph.D., author of A Fight to Be: A Psychologist’s Experience of Both Sides of the Locked Door

“In a clear manner, Dr. Williams lays out the evidence for a ‘paradigm shift’ in our thinking that, at its core, would offer people who experience madness both hope and the knowledge that robust recovery is possible, and, with the right support, quite common.” – Robert Whitaker, winner of the George Polk award for medical writing, and author of Mad in America and Anatomy of an Epidemic

Yeah, this approach has been tried and has failed (see: 1950s, Psychoanalysis).
Psychoanysists tried…and tried…to understand schizophrenic patients’ delusions and dysperceptions, all to no avail. Thankfully, Thorazine was discovered an schizophrenics could leave the wards and have a chance at life. Antipsychotics are far from a perfect solution, but they’re the best solution we have at te moment.

And there are of course psychosocial approaches that are more likely to succeed, in less time, than the old practice of just offering therapy a few times per week. One of these is the Open Dialogue approach, which Whitaker discusses in Anatomy of an Epidemic. A directory to lots of information on that method can be found at http://bit.ly/IByKPO

Whitaker and others have refuted the myth that it was antipsychotics that allowed the hospitals to be emptied. A closer look at the evidence suggests it was social policy, not medications, that emptied the hospitals. The two key factors were making disability payments available so that people still having problems could be supported outside the hospital, and a social decision to use community treatment (or sometimes non-treatment) instead of hospitals. In some areas it was well documented that hospital populations continued to increase for quite a while after antipsychotics were introduced, until other factors caused the population to fall instead.

Antipsychotics have made billions of dollars for those who sell them, and this has led to a lot of “spin” and reluctance to face honestly the overall failure of these drugs. Psychological approaches are not foolproof, but offer a better chance of real success.

I happen to strongly agree with you that psychoanalysis has failed, and that antipsychotics might have been an improvement over psychoanalys in many cases. I believe psychoanalysis turned out to be a good example of pseudo-science. I would not be surprised if the biomedical model succeeded for a while, simply because it was less harmful than the previous treatment. Is there a semantic difference between “more helpful” and “less harmful” or is everything relative? I don’t think OpenDialogue and a few other recent collective therapies have much in common with psychoanalysis, and they might help increase the rate of recovery for many people.

There was a study by Bertram Karon comparing psychoanalytic psychotherapy without drugs, therapy with drugs and conventional psychiatry for people diagnosed with schizophrenia in Detroit. The best results were with the drug free therapy, the next best were with the drugs plus therapy and the worst with conventional psychiatry.

This is counter to your assertion that drugs are better than psychoanalysis – though psychoanalytic therapy is somewhat different from classical annalysis and more akin to plain old counselling as far as I can see.

They did us therapists who had experience of working with psychosis and who got good supervision (that’s someone to talk things over with so that the therapist had the best chance of getting on well with the client).

I am sure many people have been helped by compassionate, humanistic psychoanalysts. But as a science of helping people in distress, I think it has failed to provide any real knowledge about the human mind (I think it would be misguided to attribute to psychoanalysis the discovery that a lot of people can be helped by a compassionate therapist/adviser). In too many cases, psychoanalysis shaky concepts have just been a tool to demonize, scapegoat, demean and encourage blame-gaming inside families by focusing on retrospective (i.e. arbitrary) explanations while paying little attention to problem-solving strategies for improving relationships and one’s life. It has often made it easy to abuse or shame naive people by putting retrospective thoughts or intentions in their head, with notions about the unconscious part of the mind that have been a regression compared to what was already known about it before Freud.

I don’t read anywhere, neither in this, btw excellent — thanks Ron! I immediately ordered the book, and can’t wait to read it — review, nor elsewhere that Williams advocates for a psychoanalytic approach to “psychosis” only. Psychological and psycho-social approaches are many, and other than psychoanalysis. The specific technique or method of therapy actually only accounts for 8% in regard to the outcome (cf. Scott Miller, What Works in Therapy http://scottdmiller.com/sites/default/files/What%20Works%202010.PDF ). What primarily counts is the relationship between therapist and client.

Perhaps this is where psychiatry went wrong? When it stopped being about helping people, and became a search for “real knowledge about the human mind,” whatever that is supposed to be? After all, you could hardly accuse a psychoanalyst of performing a lobotomy.

Have you seen the many studies and consequences of using these lethal drugs? There have been many posts in the news section here showing how useless and lethal these drugs are in the military and with the general population. Did you read Bob Whitaker’s books?

I’m very disappointed to see you advocating this toxic viewpoint, which definitely makes you a danger to would be patients and society at large.

So much for all the so called help you claim to have given your patients: nice chemical lobotomies to destroy their lives and cause so many ill effects and diseases, their lives will be shortened by about 25 years if they don’t kill themselves in despair first thanks to your horrific treatment of them for fake diseases invented with BIG PHARMA to push these known poisons in the first place.

I think that there is psychosis and psychosis and the fact that they are all lumped together is where the problem lies. I think that one sort of psychosis is due to emotional distress etc and doesn’t need medication just support and working through it. I know everybody is loughing at the mention of “chemical imbalance” but I think there is some truth in that as well in some cases. One good example is sleep deprivation. It has been shown that it causes excess dopamine build-up on receptors D2. Everybody knows that anxiety is caused by too much adrenaline and cortisol etc. The answer to treating psychosis is really to look into what caused it and then treat it accordingly. My son’s psychosis was due to infection, fever and sleep deprivation which psychiatrists, all doctors that they are, failed to recognise. It got diagnosed as severe mental illness and was treated as such, causing him unnecessary trauma which got ignored.

I think you are correct in pointing out that each person’s story is unique, and that good care involves looking for what is going on with the individual person. In your son’s case, it sounds like there were distinct medical problems that needed to be addressed.

I think what many of us hate about the “biochemical imbalance” language is the way it is used to narrow a focus to biochemistry and a biochemical solution (even though the proposed “solutions” usually create a very abnormal biochemical state.) Sure, all our mental states involve biochemistry – but they also involve a lot more, and these issues should be addressed. In your son’s case, the infection needed treated, and he needed sleep.

Sleep loss by the way is a key factor in psychosis and mental imbalance for many. Often the story is complex: past traumas and conflicts result in a crisis and hypervigilance that interferes with sleep, then sleep loss itself causes more extreme emotional reactions. (The excess dopamine associated with sleep deprivation by the way is not just some mechanical thing that occurs, but seems related to the person’s effort to keep awake. Biochemistry is not separate from human intentionality.)

I agree that some people get better while in psychoanalysis and with other non-pharamacologic treatments just as some improve while taking medications. This does not mean the treatment given was what led to the improvement nor does it tell us anything about what caused the condition. I currently believe there is evidence that for some people providing care in a safe and understanding environment will give the person time to heal and this is overall safer than introducing drug treatments.

It certainly can be difficult going back and trying to determine exactly what caused someone to recover, or not. But I do think it makes sense to listen to the stories of those who recovered and to compare them. One of the most common factors cited by people who recovered was a close relationships with someone who cared and believed they could recover, and that’s one thing that decent psychological treatment provides.